Klismaphilia is a sexual disorder under the group of paraphilias where sexual gratification is obtained by the use of enemas. It is rare paraphilia though anecdotal case reports are abound in literature. Most paraphilias are lifelong enduring patterns of behavior while some may be transient in nature. We present herewith a case of 66-year-old man who began to feel a sexual arousal during an enema that was administered for medical reasons and then began to use enemas regularly by himself and partner for sexual gratification. He was psychoeducated and showed a good response.

Keywords: Late life, enema, klismaphilia, paraphilia

How to cite this article:De Sousa A. Klismaphilia like behavior in late life. J Geriatr Ment Health 2015;2:60-2

Paraphilias or paraphilic disorders (sexual deviations) are disorders of sexual preference in which sexual arousal occurs persistently and significantly in response to objects which are not part of normal sexual arousal (e.g. nonhuman objects; suffering or humiliation of self and/or sexual partner; children or nonconsenting person). [1] In Diagnostic and Statistical Manual of Mental Disorders-5, the diagnostic criteria for these disorders include the pathognomonic fantasy and an intense urge to act out the fantasy or its behavior elaboration. [2] Anal eroticism and anal sexual intercourse have been reported as variants of normal sexual behavior in all individual and is widely practiced by homosexuals and lesbians. [3] Enemas as a mode of sexual pleasure have been reported as a source of sexual pleasure in anecdotal case reports over the years and is known as klismaphilia. [4] In klismaphilia, one obtains sexual gratification by the use of enemas to one's self or to others. [5] Usually paraphilias like klismaphilia are either lifelong and enduring or may transient during unusual sexual explorations. [6] We report here a rare instance in an elderly patient with no history of paraphilias or unusual sexual behavior in the past who presented with klismaphilia after he experienced intense sexual pleasure during a medically prescribed enema.

Case Report

A 66-year-old married retired engineer was brought by his wife to the outpatient clinic with chief complaints of wanting her to unnecessarily administer an enema to him daily for no reason and at odd hours like the afternoon and sometimes in the middle of the night. The wife mentioned that this started around 6 months prior to presentation when the patient was taken to his family physician in view of the fact that he had been having severe constipation and had not passed a stool since 3-4 days. The physician advised an enema, which was given by the nurse at the clinic. The wife was also taught how to administer the same so that she could do the same at home if needed. The patient told the wife after the enema that he enjoyed the experience thoroughly and also felt relieved as his bowels were evacuated fully. The wife did not bother much about the "enjoyment" aspect initially, but later when the husband demanded daily enemas, she was unable to decipher the reasons for the same. It was on speaking to the patient that he mentioned the feeling of intense sexual pleasure when administered an enema and also mentioned the same when the nurse had administered one. He said that he had never experienced such a gush of sexual excitement earlier in his life in any form of sexual experience and just could not do without it. He claimed that the enema experience was more pleasurable than any form of masturbation done by him in his life. In fact, the wife mentioned that initially when she gave in to his demands for an enema daily, there would be times where he would lie down naked to receive the enema. In fact, she noticed on a few occasions that he ejaculated on the bed during the enema but did not question him about the same. It was only when his demands for enema increased; she consulted her family physician who directed her to seek psychiatric help.

The patient on interview replicated all that the wife had mentioned. When questioned there was no deviance or abnormality in the personal sexual history of the patient and his wife. He also denied any homosexual impulses or feelings. The couple was questioned independently and no history of any psychopathology in the patient's life till the present situation was elicited. This was the first time ever in the patient's life that some sort of pervasiveness prevailed. The patient accepted that he sexually enjoyed the enema and that he felt no harm in it if an enema gave him sexual pleasure. He mentioned that he and his wife had stopped having sexual intercourse since a year since she had a lack of desire (she was 62-year-old) and this method brought him immense joy without disturbing his wife except that she had to administer the enema. He in fact never knew or thought of this as an abnormality and even tried to argue that homosexual individuals enjoy anal intercourse and that he is only using enemas. Prior to the start of the present events, he used to indulge in penovaginal sexual intercourse with his wife, once or twice a month and since the past year they stopped having intercourse due to lack of desire on part of the wife. The patient would fantasize about his wife and some other women whom he knew and would masturbate once or twice a month to manage his sexual desires. He also had normal early morning erections as per history. The enema given was a normal soap water enema, which was given via a tube inserted anally into the rectum, and the enema could be held high on a stand. The patient did mention that he got erections during the enema, but had ejaculated twice due to the intense sexual excitement. He never simultaneously masturbated, though he often had the desire to do so. There was no history suggestive of child sexual abuse, abnormal sexual feelings, sexual deviations, homosexual tendencies, and bisexuality. There was also never a feeling of wanting to administer enemas to others. There was no history of constipation later on and he was passing stools normally after the first instance of receiving an enema.

All the odd behavior had started only since 6 months prior to the presentation. The patient had gone for a complete health checkup prior to the presentation, and all reports were normal with no medical complications. The patient was advised an MRI brain from our side which was normal and showed no signs of cerebral atrophy. His Mini-Mental State Examination score was 29. These were done to rule out any ensuing dementia that could have contributed to hypersexuality and the abnormal behavior.

The patient was counseled about the problem, and he accepted that it was an abnormality with reluctance and said that he would stop asking for an enema. He and his wife were psychoeducated about how an active sexual life could be maintained post 60 years and they were advised on the same. No medication was started as the patient and wife both felt that he could control the problem without the same. The patient was followed up telephonically and at the last contact was abstaining from the same.

Discussion

There have been anecdotal reports on klismaphilia since the 1940s. [7] There has been to the best of our knowledge no report of klismaphilia like behavior with an onset after the age of 60 years. Treatment guidelines and management issues are not well-defined due to lack of a large number of cases. Even amongst the paraphilia related disorders, it remains rare. [8] The index patient had symptoms for a 6 months and accepted though with reluctance that his behavior was abnormal. The acceptance led to a resolution of symptoms along with the fact that he was amenable to counseling. In paraphilias, acceptance of a psychopathology is rare, and hence treatment is difficult. [9] Hypersexuality in old age has been reported to be a part of behavioral symptoms of dementia, which has been often noted by family members. [10] Sexually deviant behavior however with an onset in old age is rarely reported. Another factor in our index case was the fact that he was aware of his problem when brought to us and did not mind seeking help for the same which normally may not be the case in paraphilic behavior. This case report aims to make clinicians aware of this rare yet possible paraphilic behavior and the fact that sexual deviances could arise for the first time in late life.